HEALTH PROMOTION INTERNATIONAL Vol. 18. No. 4 Oxford University Press 2003 doi: 10.

1093/heapro/dag414

All rights reserved Printed in Great Britain

Determinants of the use of maternal health services in rural Bangladesh

NITAI CHAKRABORTY1, M. ATAHARUL ISLAM1, RAFIQUL ISLAM CHOWDHURY2, WASIMUL BARI1 and HALIDA HANUM AKHTER3
Department of Statistics, Dhaka University, 3Bangladesh Institute of Research for Promotion of Essential and Reproductive Health and Technologies (BIRPERHT), Dhanmondi R/A, Dhaka, Bangladesh and 2Department of Health Information Administration, Kuwait University, Kuwait
1

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SUMMARY
Utilization of health services is a complex behavioral phenomenon. Empirical studies of preventive and curative services have often found that use of health services is related to the availability, quality and cost of services, as well as to social structure, health beliefs and personal characteristics of the users. In this paper an attempt is made to examine the factors associated with the use of maternal health care services in Bangladesh on the basis of data from a survey of maternal morbidity in Bangladesh, conducted by the Bangladesh Institute of Research for Promotion of Essential and Reproductive Health and Technologies (BIRPERHT). The results from both the bivariate and multivariate analyses confirmed the importance of mothers education in explaining the utilization of health care services. Female education retains a net effect on maternal health service use, independent of other womens background characteristics, households socioeconomic status and access to healthcare services. The strong influence of mothers education on the utilization of health care services is consistent with findings from other studies. Women whose husbands are involved in business/services also positively influenced the utilization of modern health care services. However, the study results are inconclusive with respect to the influence of other predisposing and enabling factors, such as womens age, number of previous pregnancies and access to health facilities. Multivariate logistic regression estimates do not show any significant impact of these factors on the use of maternal health care. The influence of severity of disease condition in explaining the utilization of maternal health care appears to be significant. Multivariate analysis indicate that women having had a life-threatening condition are little over two times more likely to seek care from a doctor or nurse to treat their maternal morbidities.

Key words: health services; maternal health; morbidity; prospective study

INTRODUCTION Millions of women in developing countries experience life threatening and other serious health problems related to pregnancy or childbirth. Complications of pregnancy and childbirth cause more deaths and disability than any other reproductive health problems (EC/UNFPA, 2000). The situation is worse in developing countries like Bangladesh due to inadequate access to modern health services and poor utilization. Despite the governments serious commitment to deliver health facilities to the doorsteps of common people through innovative approaches, such as Essential Service Package (ESP), the utilization of health services is still far below any acceptable standard. One of the public health challenges in developing countries such as Bangladesh is, therefore, to
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identify vulnerable groups and to provide them with needed preventive and curative health services. Utilization of health services is a complex behavioral phenomenon. Empirical studies of preventive and curative services have often found that the use of health services is related to the availability, quality and cost of services, as well as social structure, health beliefs and personal characteristics of the users (Andersen and Newman, 1973; Kroeger, 1983; Becker et al., 1993; Sarin, 1997). It is well recognized that womens current age plays an important role in the utilization of medical services (Fiedler, 1981; Elo, 1992; Fosu, 1994). Mothers age may sometimes serve as a proxy for the womens accumulated knowledge of health care services, which may have a positive influence on the use of health services. On the other hand, because of development of modern medicine and improvement in educational opportunities for women in recent years, younger women might have an enhanced knowledge of modern health care services and place more value upon modern medicine. Several studies have found a strong association between birth order and use of health care services (Wong et al., 1987; Elo, 1992). Because of perceived risk associated with first pregnancy, a woman is more likely to seek maternal health care services for first order than higher-order births. Having more children may also cause resource constraints, which have a negative effect on health care utilization (Wong et al., 1987). Women with a large number of children underutilize available health services because too many demands on their time force them to forgo health care (McKinlay, 1972). One of the important predisposing factors for utilization of health care is family size. Women from large families underutilize various health care services because of too many demands on their time. Larger families also cause resource constraints, which have a negative effect on health care utilization (Wong et al., 1987). It is well recognized that mothers education has a positive impact on health care utilization. In a study in Peru using DHS data, Elo (Elo, 1992) found quantitatively important and statistically significant effect of mothers education on the use of prenatal care and delivery assistance. In another study, Becker and colleagues (Becker et al., 1993) found mothers education to be the most consistent and important

determinant of the use of child and maternal health services. Several other studies also found a strong positive impact of mothers education on the utilization of health care services (Fosu, 1994; Costello et al., 1996). It is argued that better educated women are more aware of health problems, know more about the availability of health care services, and use this information more effectively to maintain or achieve good health status. Mothers education may also act as a proxy variable of a number of background variables representing womens higher socioeconomic status, thus enabling her to seek proper medical care whenever she perceives it necessary. It is well known that increased income has a positive effect on the utilization of modern health care services (Elo, 1992; Fosu, 1994). Husbands occupation can be considered a proxy of family income, as well as social status. Differences in attitudes to modern health care services by occupational groups depict occupation as a predisposing factor. Alternatively, viewing occupation as proxy to income, which enables acquisition of more and better health care, depicts it as an enabling factor (Fiedler, 1981). The most important variable associated with utilization of MCH services is the physical accessibility of these services (Abbas and Walker, 1986). Several other studies also found that physical proximity of health care services, especially in the developing countries, plays an important role in utilization of these services (Stock, 1983; Airey, 1989; Paul, 1991). In this study, access refers to the availability of health care services in closer proximity to the users. Due to unavailability of information, other aspects of access/availability such as cost of services, the quality of services offered and time required to receive the services were not considered in this study. In a study in Bangladesh, Rahaman and colleagues found that geographical distance is one of the most important determinants of health care service utilization in rural areas (Rahaman et al., 1982). The purpose of this paper, therefore, is to examine the factors that influence the use of maternal health care services in Bangladesh by using the prospective data obtained from the survey on Maternal Morbidity in Bangladesh, which was conducted by the Bangladesh Institute of Research for Promotion of Essential and Reproductive Health and Technologies (BIRPERHT). We have employed this data set, although it was conducted during 19921993, for

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two compelling reasons: (i) this is the only prospective data set on maternal morbidity at national level covering a wide range of issues; and (ii) there has been little change in reproductive health-care-seeking behavior in recent years, as observed in various demographic and health surveys (NIPORT, 1994; NIPORT, 1997; NIPORT, 2001). Identification of individual factors that may facilitate or impede the effective use of health care services for treating maternal morbidity may help us to identify those who may be particularly vulnerable, and provide information that policy makers can use to target services to those in greatest need. METHODS Data source This paper is based on data from a survey of maternal morbidity in Bangladesh, conducted by BIRPERHT (Akhter et al., 1996). Data collection spanned the period November 1992 to December 1993. The study had two components: crosssectional and prospective. This paper employed data from the prospective component. This study was conducted after securing the necessary permission from the Institutional Ethics Committee known as the Human Subjects Committee of the BIRPERHT. Multi-stage random sampling was employed to collect data on maternal morbidity. One district from each of four divisions was selected in the first stage. In the second stage, one thana (a thana contains several unions, comprising a population size of 0.20.25 million) from each selected district was selected randomly. Finally, two unions (unions consist of several wards, which are small geographical boundaries comprising villages in rural areas) from each selected thana were considered study areas. For the prospective study, 1020 pregnant women (pregnant for 6 months) were interviewed. Prospective subjects were followed-up with an interval on average once a month, through full-term pregnancy, delivery and until 90 days postpartum or 90 days after any other pregnancy outcome. Information was collected on socioeconomic status, background, pregnancy-related care and practice, extent of morbidity during the index pregnancy, delivery, and postpartum period or abortions (Akhter et al., 1996). For this analysis we selected 993 pregnant women out of 1020 who had at least one antenatal

Table 1: The number of respondents interviewed during each follow-up period (n 993)
Follow-up 1 2 3 4 5 6 7 8 Frequency 992 917 771 594 370 148 34 1 Percentage 97.3 89.9 75.6 58.2 36.3 14.5 3.3 0.1

follow-up. To avoid complications arising from the association among repeated observations on the same individual, we considered only first occurrence of specific disease conditions in any follow-up. Among the selected pregnant women, progressively large proportions were lost to followup at each subsequent interview. Table 1 shows the exact number of respondents interviewed during each follow-up. Respondents entered into the study at different times in their pregnancies, hence we observe that after the first two follow-ups the number of respondents decreased sharply. Information on treatment corresponding to specific disease condition at follow-up was considered to examine differentials in the use of maternal health services. The data were collected through participant interview of the selected pregnant women during each follow-up. Conceptual framework The model of utilization of maternal health services used in this analysis is based on the conceptual framework of health-seeking behavior developed by Anderson and Newman (Anderson and Newman, 1973). This behavioral model proposed that the use of health care services is a function of three sets of individual characteristics: (i) predisposing characteristics, e.g. age, household size, education, number of previous pregnancies, health-related attitude; (ii) enabling characteristics, i.e. income, characteristics of health care system and accesses, and availability of health facilities; and (iii) need characteristics, i.e. characteristics of illness, perceived health status, and expected benefit from treatments. Fosu argues that the predisposing factors reflect the fact that families with different characteristics have a different propensity to use

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N. Chakraborty et al. Table 2: Independent variables used in the analysis: categories and percentage distribution
Variable Demographic variables Womens age (years) 20 2034 35 Age at marriage (years) 15 15 Number of previous pregnancies 0 14 5 Family size 3 46 7 Socioeconomic variables Mothers education None Primary Secondary Husbands occupation Business/services Farmer Day laborer Other Womens gainful employment Yes No Economic status Good Average Poor Type of housing Cement/tin Rudimentary Access variable Distance from health facility 1 km 1 km Total number Percentage Number

health care services, while the enabling factors reflect the fact that some families, even if predisposed to use health services, must have some means to obtain them, i.e. income, access, and availability of health services (Fosu, 1994). According to Andersen and Newman, the need factor is the most immediate cause of health service use (Andersen and Newman, 1973). The need factor reflects the perceived health status, as indicated by severity of the morbidity conditions or the number of morbidities. The presence of predisposing and enabling components may not be enough for a mother to seek health care. She must perceive the disease as serious and believe that the treatment will provide the expected benefits (Fosu, 1994). Need represents the most immediate cause of health service use. Need for health care can be measured in a variety of ways: self-perceived health status, number of morbidity symptoms, or duration and severity of disability (Fiedler, 1981). Perceived severity or number of episodes of diseases have a positive association with health care utilization (Fosu, 1994). Dependent variable For life-threatening and high-risk diseases the dependent variable, i.e. the use status variable, was constructed from combined responses to a question about whether the respondent had obtained any advice/treatment, with responses to a follow-up question on the particular place or practitioner consulted. Responses to these questions were categorized into three categories: whether the women obtain services from a doctor or a trained nurse/family welfare visitor (FWV; trained health personnel for family planning and pregnancy-related services in the unions), whether she received services from other sources, or whether she received no treatment. In order to study the influence of explanatory variables on the utilization of health care services for morbidity during the antepartum period, some of the high risk disease conditions were combined to ensure a sufficient number of cases for meaningful analysis. The use status of health services for high-risk morbidity is coded as follows: 2 if the women obtained services from a doctor or a trained nurse/FWV corresponding to the occurrence of any one of the high-risk diseases for the first time; 1 if the women received services from other sources; and 0 for no treatment. The number and percentage

33.1 61.3 5.5 46.3 53.7 27.1 57.1 15.8 28.5 40.4 31.1 54.8 28.4 16.8 40.2 33.9 18.8 7.0 31.4 68.6 20.1 55.7 24.2 65.7 34.3 42.3 57.7

329 609 55 460 533 269 567 157 283 401 309 544 282 167 399 337 187 70 312 681 200 553 240 652 341 420 573 993 Downloaded from heapro.oxfordjournals.org by guest on March 15, 2011

distribution of respondents by selected characteristics are shown in Table 2. RESULTS Antepartum morbidities The morbidity conditions are categorized into life threatening/high risk and presence of other medical conditions. Life-threatening and high-risk morbidities include excessive bleeding, fits and convulsion, edema, fever 3 days and hyperemesis, while other conditions include

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lower abdominal pain, palpitation and burning sensation during micturation. To ensure a sufficient number of cases in order to examine the factors associated with health services utilization, all morbidity cases during the antepartum period (past and present) have been considered in this analysis. Therefore, the results do not represent the prevalence rate in the true sense. Table 3 shows the percentage of respondents who reported different illness for the first time during the antepartum follow-up period, and the corresponding treatment behavior. Among the life-threatening conditions, fits/convulsions were reported by 17.7% of the respondents, followed by excessive bleeding (12.5%). It is evident that the highest percentage of respondents (46.4%) reported the high-risk conditions cough and fever for 3 days. Hypermesis was reported by 28.2% of women, while edema was reported by 22.1% of respondents. Among other morbid conditions, abdominal pain (87.4%) was found to be the most common illness during pregnancy in the sample. About 87% of respondents reported to be ill at least once during their pregnancy, followed by palpitation (75.6%) and burning sensation during micturation (57.5%). Care-seeking behavior for antepartum morbidities For each reported problem, respondents were asked whether they sought care and what the source of that care was. The results in Table 3 indicate that for life-threatening diseases such as

excessive bleeding and fits/convulsion, a majority of respondents sought some treatment. However, the prevalence of adequate care was very low. Only 42.6% of respondents who reported fits/convulsion during pregnancy sought care from qualified medical personal, i.e. from a doctor, nurse or FWV. This coverage is even lower for excessive bleeding, where only 32.3% having had this condition went to a doctor, nurse or FWV. About 46% of respondents did not seek any care for excessive bleeding and another 21.8% went to a village doctor/kabiraj (practitioner of herbal medicine) and other traditional sources, which are not adequate for treating life-threatening conditions such as excessive bleeding. Among those who reported a high-risk disease like edema, 73% did not seek any care and only 14.2% sought care from a doctor, nurse or FWV. Over 62% of respondents who reported having experienced excessive vomiting during follow-up did not seek any medical care, while only 17.1% sought care from a doctor, nurse or FWV. The situation is comparatively better for treating fever 3 days during pregnancy; ~22.3% of the respondents who had reported to have had fever received some care from a doctor, nurse or FWV, while another 28% sought care from other sources. Among those who had suffered from other medical conditions such as abdominal pain, palpitation and burning sensation during micturation, a very low proportion went to see a doctor, nurse or FWV (9.3%, 11.7% and 9.1% for each condition, respectively).

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Table 3: Percentage of respondents reporting problems and percentage of those with reported problems who sought treatment during pregnancy, according to morbidity type
Type of morbidity Reporting problems (n 993) Type of treatment received Doctor/nurse/FWV Life threatening/high risk Hemorrhage Fits/convulsions Edema Hypermesis Cough/fever ( 3 days) Other medical conditions Lower abdominal pain Palpitation Burning micturition Any current complications FWA/TBA/others No treatment n

12.5 17.7 22.1 28.2 46.4 87.4 75.6 57.5 86.2

32.3 42.6 14.2 17.1 22.3 9.3 11.7 9.1 28.3

21.8 34.7 12.8 20.7 28.0 11.9 5.6 10.7 13.3

46.0 22.7 73.1 62.1 49.7 78.8 82.7 80.2 58.4

124 176 219 280 461 868 751 571 856

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Differential pattern of utilization of health care services In specifying the determinants of health service use for treating maternal morbidities during the antepartum period, we examined the bivariate effects of some selected background characteristics, which are grouped as: (i) predisposing; (ii) enabling; and (iii) need factors. Among the predisposing factors considered in this study are respondent age, number of

previous pregnancies, age at marriage, family size and mothers education. Husband occupation, housing materials, economic status, womans employment, and access to health facilities are the enabling factors selected in this study. The results presented in Table 4 represent the bivariate analysis of explanatory variables on the use of health care for treating any current complications reported by the respondent for the first time during follow-ups. To examine the effects

Table 4: Percentage of respondents who had any current complications, by type of treatment received and background characteristics
Characteristics Type of treatment received Doctor/nurse/FWV Medical assistant/ FWA/TBA/others None n Downloaded from heapro.oxfordjournals.org by guest on March 15, 2011

Predisposing factors Womens ageb (years) 20 2034 35 Age at marriageb (years) 15 15 Number of previous pregnanciesa 0 14 5 Family sizea 3 46 7 Mothers education No education Some primary Secondary or higher Enabling factors Husbands occupationb Business/services Farmer Laborer Others Womens gainful employmentb No Yes Economic status Poor Average Good Type of housing Rudimentary Cement/tin Distance from health facility 1 km 1 km Total
a

28.5 27.1 42.0 31.9 25.2 29.0 26.1 35.1 30.3 23.2 33.6 26.5 28.8 34.6 33.4 24.1 24.1 32.7 25.3 35.4 27.4 28.9 28.1 27.4 29.0 29.3 27.7 28.3

12.8 13.1 24.0 15.8 11.6 13.6 12.4 17.6 13.4 13.6 13.8 12.4 16.5 12.8 18.2 11.0 8.4 14.5 13.9 13.1 9.6 14.7 15.6 12.9 14.0 13.0 14.0 13.3

58.3 59.8 34.0 52.2 63.2 57.5 61.5 47.3 56.3 63.2 52.6 61.1 54.7 52.6 48.4 64.8 67.5 52.7 60.8 51.5 63.0 56.4 56.3 59.7 57.0 57.6 58.3 58.4

274 528 50 404 448 221 483 148 231 353 268 476 243 133 341 290 166 55 592 260 208 477 167 303 549 368 484 852

0.05; bp

0.01.

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of predisposing and enabling factors on health care utilization in the presence of need factors, bivariate analysis was performed for utilization of health care for the treatment of lifethreatening diseases. The results are presented in Table 4. Respondent age The results from bivariate analysis suggest that older women are more likely to seek maternal health-care services than younger women (Table 4). About 42% of older (age 35 years) respondents sought care for any current complication from a doctor or nurse, compared with 28.5% of younger women (age 20 years). Number of previous pregnancies The results from this study indicate a U-shaped relationship with birth and the use of health services to treat maternal morbidities (Table 4). The percentage of women who sought care from a doctor, nurse or FWV to treat any complications decreases from 29% in women with no previous pregnancies to 26.1% in mothers with one to four previous pregnancies; it increases again to 35.1% in women with five or more previous pregnancies. The use of traditional and other health services related to the number of previous pregnancies also show a similar pattern. Family size The results show a U-shaped relation between family size and the use of health services for treating any complications during pregnancy. The percentage of women who sought care from qualified medical personnel, i.e. a doctor, nurse or FWV, to treat complications decreases from 30.3% in women with less than four family members to 23.2% among mothers with four to six family members, and increases again to 33.6% in women with seven or more family members. The use of traditional and other health services does not show a similar pattern in relation to family size. Mothers education The results from this study also supports the positive association between the level of mothers education and health care utilization. The percentage of women who sought care from qualified medical personal for treating complications increases from 26.5% among illiterate women to 34.6% among women with secondary or higher education.

Husbands occupation The study shows that women whose husbands worked in business or services were most likely to be users of modern health care services to treat complications during pregnancy. About 33.4% of women whose husbands worked in business or services went to some qualified medical personnel for treatment, compared with 24% among those whose husbands worked in agriculture or as day laborers (Table 4). Womens employment Womens involvement in gainful employment is one of the important factors positively affecting the use of quality medical care to treat complications. This also empowers women to take part in decision-making processes about health care in the family. Results from this study indicate that women who are involved in gainful employment are more likely to use modern health care services to treat complications during their pregnancy. About 35.4% of women who worked for cash went to some qualified medical personnel for treatment, compared with only 25.3% of those who did not work. Type of housing Type of housing, like occupation, can also be considered a proxy for socioeconomic status of the household and may have a similar impact upon the utilization of health care. The results indicate that women who belong to families with houses made of cement or tin are more likely to seek treatment from qualified medical personnel. About 29% of women living in pucca/tin houses went to doctors/nurses, compared with 27.4% who lived in rudimentary houses (Table 4). However, the differences were not found to be statistically significant. Access to health facility There was no substantial difference in utilization of health care services for complications according to how far respondents lived from health facilities. This result is quite surprising because the respondents residing in close proximity to health care services are more likely to use them. Need factor: disease status We considered severity of disease, i.e. lifethreatening conditions, as a need factor to examine the effect of predisposing and enabling factors on health care utilization in the presence

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of need factors. The results presented in Table 5 group the percentage of respondents who had high-risk complications according to whether they received treatment or not. We observed that mothers education (p 0.05), age at marriage (p 0.10) and type of housing (p 0.10) appeared to be associated positively with treatment received, while family size (p 0.10) was negatively associated with receiving treatment for complications. Multivariate analysis In previous sections, bivariate analysis of health care utilization by several background characTable 5: Percentage of respondents who had highrisk complications, by type of treatment received and background characteristics
Background characteristics Treatment received Yes Predisposing factors Womens age (years) 20 20 Age at marriagea (years) 15 15 Number of previous pregnancies 0 1 Family sizea 4 4 Mothers educationb No education Primary or higher Enabling factors Husbands occupation Business/service Others Womens gainful employment No Yes Economic status Poor Good Type of housinga Rudimentary Cement/tin Distance from health facility 1 km 1 km Total
a

No

33.3 28.7 26.6 34.9 37.0 28.6 37.3 27.5 26.1 37.0 29.6 30.5 27.8 34.5 31.3 29.9 26.0 34.4 29.2 30.8 69.9

66.7 71.3 73.4 65.1 63.0 71.4 62.7 72.5 73.9 63.0 70.4 69.5 72.2 65.6 68.8 70.1 74.0 65.6 70.8 69.2 30.1

75 174 143 106 46 203 67 182 157 92 98 151 162 87 48 201 127 122 106 143 249

0.10; bp

0.05; cp

0.01.

teristics, categorized as predisposing and enabling factors, has been performed to examine the nature of association between these factors and health care use status. Numerous associations were found to be significant in the bivariate analysis. However, bivariate association between two variables does not necessarily imply a significant causal relationship between them. Therefore, a multivariate approach was applied to determine which factors best explain and predict health care service use outcome. For multivariate analysis, a trichotomous logistic regression was employed. To include need factor in the model, the use status variable was constructed by combining responses to treatment for any current complications and for lifethreatening disease conditions during pregnancy. The use status of health service was coded 2 if the women obtained services from a doctor or a trained nurse/FWV, 1 if the women received services from other sources, and 0 for no treatment. The details of the trichotomous logistic regression are reported elsewhere (Hosmar and Lemeshow, 1989). All the significant variables in the bivariate analysis were included in the model. Because of its importance in explaining the differentials in utilization of maternal health care, mothers education was also included in the model, even if it was not found to be significant in the bivariate analysis. The model appears to be significant (p 0.001) for the selected characteristics. The estimates, odds ratios (OR) and 95% confidence intervals (CI) are presented in the Table 6. In the trichotomous logistic regression model for health care use, older women had increased odds of using both modern and traditional health care service compared with younger women (age 20 years). Women who married at age 15 years were less likely to use both modern and traditional health care services compared with those who married at 15 years of age. Women with smaller family sizes and with higher previous pregnancy experience were more likely to seek health care from qualified medical personnel. However, none of the above independent variables has a statistically significant impact upon health care utilization. Mothers education is likely to be associated with many of the other determinants considered in this study. The results indicate that female education has a net effect on maternal health service use, independent of other background characteristics, household socioeconomic status

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Maternal health services in rural Bangladesh Table 6: Estimates of parameters of trichotomous logistic regression of health care service utilization for maternal morbidity during pregnancy
Variables Type of treatment (ref Doctor/nurse/FWV Estimate Predisposing factors Womens age (years) (ref 20 years) 2034 0.117 35 0.643 Womens age at marriage (years) (ref 15 years) 15 0.449b Family size (ref 7) 3 0.184 46 0.430a Number of previous pregnancies (ref 0) 14 0.156 5 0.209 Mothers education (ref no education) Some primary 0.247 Secondary or higher 0.611b Enabling factors Household type (ref good) Bad 0.109 Husbands occupation (ref farmer) Business/service 0.610b Day laborer 0.043 Other 0.746a Economic status (ref poor) Good 0.025 Need factor Disease status (ref other) High risk 0.786b Constant 1.085b
a

335

no treatment) Other/traditional Estimate OR 95% CI

OR

95% CI

1.124 1.903 0.638 1.202 0.650 0.856 1.232 1.280 1.842 0.896 1.840 1.044 2.108 1.025 2.195

0.7221.749 0.7844.617 0.4500.905 0.7481.932 0.4350.972 0.5351.370 0.6242.434 0.8611.901 1.1153.043 0.6161.305 1.2602.686 0.6311.729 1.0644.176 0.6691.571 1.5143.183

0.255 1.004 0.474a 0.547 0.069 0.381 0.047 0.046 0.224 0.085 0.081b 0.220 0.816 0.540 0.798b

1.29 2.73 0.622 1.728 1.072 0.683 0.954 1.501 1.251 0.918 2.228 0.802 2.262 1.717 2.221 2.514b

0.7142.330 0.9258.046 0.3950.981 0.9223.239 0.6371.803 Downloaded from heapro.oxfordjournals.org by guest on March 15, 2011 0.3661.276 0.3962.302 0.9122.473 0.6292.487 0.5611.503 1.3653.637 0.3901.649 0.9155.591 0.9493.106 1.3833.567

0.05; bp

0.01.

and access to health care services. Women with secondary or higher education are almost 1.8 times more likely to seek treatment from doctors/nurses to treat their antepartum morbidities. Among the enabling factors, husbands occupation seems to be an important determinant of maternal health care use, indicating that wives of men who work in business/service are more likely to seek treatment from a doctor or nurse compared with wives of farmers ( p 0.01). Women from families in good economic condition are more likely to receive treatment from a doctor or nurse. However, the positive impact of higher economic status on health care use was not found to be statistically significant. The most important factor in explaining the utilization of maternal health care that arises from logistic regression is the need factor, i.e. severity of disease. The coefficient of the need

factor was found to be highly significant (p 0.01). Women having had a life-threatening condition are 2.2 times more likely to seek treatment for their maternal morbidities from a doctor or nurse. CONCLUSION In this paper we examined a number of predisposing and enabling factors that influence the use of maternal health care services. The results show a high level of association between certain predisposing and enabling factors and use of maternal health services. The results from both bivariate and multivariate analysis confirmed the importance of mothers education on the utilization of health care services. Female education retains a net

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effect on maternal health service use, independent of other background characteristics, households socioeconomic status and access to health care services. The strong influence of mothers education on the use of health care services is consistent with the findings from other studies (Abbas and Walkerns, 1986; Elo, 1992; Becker et al., 1993; Fosu, 1994). Also, womens whose husbands are involved in business/services are more likely to use both modern and traditional health care services. However, the study results are inconclusive on the influence of other predisposing and enabling factors such as womens age, number of previous pregnancies and access to health facilities. Trichotomous logistic regression estimates do not show any significant impact of these factors on the use of maternal health care. The influence of need factor, i.e. severity of disease condition, in explaining the utilization of maternal health care has been found to be highly significant ( p 0.001) using logistic regression. Multivariate analysis indicates that women who have had a life-threatening condition are 2.2 times more likely to seek care from a doctor or nurse to treat their maternal morbidities. The main strength of the study deserves mention: the study is based on current information collected during antenatal followups, which requires less memory recall. The limitations also need to be noted. The sample size did not permit separate examination of utilization of health care services according to specific disease condition.

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ACKNOWLEDGEMENTS The authors would like to thank Mahbub E. Elahi Khan Chowdhury and Arindom Sen of BIRPERHT for their assistance during different phases of this work. We also thank Dr J. Chakraborty for his help with preparation of the manuscript. The authors are greatly indebted to the Ford Foundation for funding data collection for the maternal morbidity study.
Address for correspondence: Rafiqul Islam Chowdhury P.O. Box 31470 Sulaibekhat 90805 Kuwait E-mail: rafiq@hsc.kuniv.edu.kw

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